AgriBev Stable Craft Order Form 2024:

CUSTOMER ACCOUNT SETUP FORM

Please ensure all required fields are filled out and submit this form to set up your account and communication preferences.
Full Name Person Completing Form*

First NameLast Name
Email*
Contact Number*
Name of Business/DBA*
VA ABC License #:*
Name on VA ABC License*
Take Photo of Va ABC License
File Upload License

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ABC License Expiration Date*

MonthDayYear
Date
Business Phone Number*
Please enter a valid phone number.
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website of Business
Name of Business Proprietor*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Hours of Operation, use Zero if Closed*

Person Responsible for Ordering *

First NameLast Name
Email Adress*
Cell Phone Number to Receive Text Notifications*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Buyer Name*

First NameLast Name
Cell Phone Number to Receive Text Notifications*
Please enter a valid phone number.
Email*
Each week we will send a notification reminder, which do you prefer?*
These selections will receive notifications based on your preferences.
Monthly Newsletter Subscription Would you like to receive our monthly newsletter featuring new products and programs?*

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COD Payment Type*
By submitting this information, we can ensure a smooth process for adding your business to our system and provide a tailored experience moving forward.
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CUSTOMER ACCOUNT SETUP FORM